Helping Someone with BPD

*Note: The source of this document is http://www.dbtsf.com/helping-someone.htm#validation


by Michael Baugh

Emotional disorders and self-destructive behaviors are troubling not only to the person who has them, but to the friends, family and loved ones of that person. It may be that you have come to this site in order to find out how you can help someone who may meet criteria for Borderline Personality Disorder (BPD) or related mood disorders.

Perhaps you are also hoping that you will find ways to help yourself and other family members deal more effectively with the anger, unpredictability, depression, substance abuse, cutting or suicide attempts that these emotionally vulnerable people often display. People who live with loved ones exhibiting borderline behaviors often become stressed out, and feel like they are "walking on eggshells" to avoid emotional blowups or more destructive behaviors.

It can help to know that you are not alone in struggling with these difficulties, that books and websites are available to provide helpful information, and that mental health professionals now have powerful tools to assist not only your loved one, but you as well. The way that I work with the families of people who exhibit borderline behaviors is based upon Dialectical Behavior Therapy (see What is DBT? for more information).

Getting Professional Help
Families who have sought my help for someone with BPD have usually hoped that I could that I could help get the person into a treatment process that would improve moods and behavior, and help the family members deal with their own stress reactions, communicate in ways that allow them to assert reasonable boundaries without causing huge blowups, and conduct themselves in ways that support their loved ones to get moving in life to become happier. Because people with borderline behaviors often respond defensively (and angrily) to the suggestion from family members that they need help, it is likely to take time, patient persistence, and improved communication skills on the part of family members before the person they want to help becomes involved in treatment.

Therefore I usually begin working with the family members themselves on skills that will help set the limits they need for the happiness of their own lives, communicate as effectively as possible their desire for the person with borderline behaviors (the PBB) to get help and make life changes, accept their own limitations in what they are able to do to make their loved one happy, and discover ways that their efforts to avoid conflict or help the PBB may have inadvertently reinforced the very behaviors that drive the family crazy.

Avoiding conflict
While it is natural, for example, to avoid bringing up difficult topics with someone who is likely to get real upset, in failing to do so family members often end up going along with things that make them unhappy. What's worse, these attempts to avoid conflict strengthen the borderline brain and behavior patterns of the loved one, and make them more likely to occur in the future. So part of my job in helping family members is to support them to stand up more for their own boundaries, even if this is unpleasant in the short run, so that things get better for everyone (including the PBB) in the long run.

It is very important, however, to carry out this process of "observing one's own limits" (as DBT calls it) in a skillful manner, balanced by love and empathy for the PBB's very real difficulties. The skills I teach families are mostly drawn from Dialectical Behavior Therapy. Before describing them in more detail, I want to mention the crucial importance of another DBT concept, Validation.

Validation
There are few things people want more in life than to be told that they are right about what they are thinking, feeling and doing. Upon being told this, people usually calm down and feel better, which makes communicating with them much easier.

Validation basically involves communicating that we understand, appreciate or approve of something in another person, such as their beliefs, emotions or actions. Though we may not be able to validate everything someone feels or does (especially with destructive behaviors) we can learn to find something in the person's feelings or behaviors that we can understand and agree with. This can be like sorting through a big pile of sand (or in a really tough moment, through a pile of manure) for nuggets of gold. We may need to get out our magnifying glasses (and shore up our faith that there is something worthwhile to find), but when we are able to offer validation it has a tremendously positive effect. This is especially true for PBB's, because they almost constantly feel misunderstood and blamed, particularly within themselves. If family members can learn to validate what is indeed valid in a skillful manner, they will usually be heard in a whole new way by their PBB.

How to Validate
Learning to validate more frequently involves perceiving what to validate and communicating about that. There's a DBT saying, "Don't validate the invalid!" You want to respond positively only to that which you genuinely experience as true and useful, or you will decrease your own sense of self-esteem by violating your values, and you will come across as sarcastic or phony. You can get in the habit of validating more often by asking yourself, "what can I agree with in this person's behavior?", or "What about this makes sense to me?" In searching for what to validate, look past the parts that bother you or you disagree with, to what seems the most worthwhile, and start there in your feedback.


As a fallback approach, you can almost always validate on the basis of the person's history or brain chemistry: "Given what you've gone through with [fill in the blank] it makes sense to me that you're feeling [fill in the blank]. I'd feel that way too if I'd experienced what you have." However, if you can find something you can agree with in a more direct way (e.g. " Yes, it sounds like that person really was rude"), that will be more powerful in helping a person calm down and feel understood.

The Validation Sandwich
If you start a conversation with validation, the person you're speaking with will probably be more receptive to whatever else you have to say. If there is difficult feedback you need to give, you can wrap it in validation before and after, like the meat between pieces of bread in a sandwich. Even more effectively, you can express the difficult feedback in the DEAR MAN format (see the DBT Interpersonal Skills page).

Dealing with Disappointment about a Loved One
It is natural to feel disappointed if your child or spouse repeatedly behaves in a way that is dramatically (or traumatically) different from what you had hoped. There may need to be a process of facing this grief in a conscious way, in moving toward acceptance of what actually is. Paradoxically, acceptance of things as they currently are supports finding the strength to make the changes we desire - -otherwise we exhaust ourselves in an inner struggle against what is going on. DBT teaches a balancing of Radical Acceptance with other distress tolerance techniques that shift our awareness to nurturing, non-harmful activities that provide an energy rebuilding respite (see Distress Tolerance Skills).

It is also helpful to focus attention on the positive aspects of our families (like the glass half-full of water), despite how extreme the difficulties may be. Learning to have more control of where we place our attention is a primary goal of mindfulness techniques taught by DBT therapists (see Mindfulness Skills).

Dealing with Guilt
Parents or loved ones may feel guilt as a result of believing (or perhaps being told by a blaming mental health culture) that they have caused or contributed to the problems of a person with borderline behaviors. It is important to remember that there is a powerful biological and genetic component to the emotional sensitivity and vulnerability of PBB's. It has usually been my experience that the families I have worked with have done the very best job they could, given their own life difficulties and lack of knowledge about the techniques that are now available for dealing with sensitive children. It is one of the paradoxes in helping someone with BPD that loved ones have done the best they could, but in order to be happy and more effective they must learn how to do better.

Learning DBT Skills
Research by Perry Hoffman, PhD and others has shown that teaching DBT Skills to family members has positive effects both in helping someone with BPD and helping the family members themselves. When parents learn improved skills in regulating emotion, tolerating distress, controlling attentional focus, and interpersonal relating they can support the development of these skills in the loved one they want to help, and will be calmer and happier themselves.

You will find in these web pages an overview of the DBT Skills (see Skills for a Life Worth Living). There are a least three good workbooks on the subject, listed below, through which you may study them on your own. You may also find it useful to consult a DBT therapist to help you apply them in your family.

Useful Books for Helping Someone with BPD
Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder by P.T. Mason and R. Kreger, (Oakland: New Harbinger, 1998). Written from the perspective of partners of people with BPD.
New Hope for People with Borderline Personality Disorder by Neil. R. Bockian, PhD, with Valerie Porr, MA and Nora Elizabeth Villagran, MA (New York: Three Rivers Press, 2002). Valerie Porr's chapter "Family Perspective of Borderline Personality Disorder" will be helpful to family members.

Books for Learning DBT Skills
Skills Training Manual for Treating Borderline Personality Disorder by Marsha Linehan (New York: The Guilford Press, 1993). By the creator of DBT, the book has handouts used by most DBT Skills Trainers. The handouts are good for putting up on the refrigerator as reminders, but some additional explanation is needed. The first half of the book includes notes for trainers that could be read as explanation of the handouts.

Don't Let Your Emotions Run Your Life: How Dialectical Behavior Therapy Can Put You in Control by Scott Spradlin, MA (Oakland: New Harbinger Publications, 2003). This book has useful explanatory text about the skills, as well as exercises and worksheets.

Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression and Anxiety by Thomas Marra, PhD (Oakland: New Harbinger Publications, 2004). This book also has explanatory text, some very good descriptions of mindfulness, and an alternate set of acronyms for DBT skills.

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